Aetna Says Doctor Made Billing Error, But The Patient Is The One Who Owes $6K For MRI

The wonderful world of medical billing, where not up is down, left is right, and the patient is somehow the one left with a hefty bill if their surgeon screws up on the paperwork.

The L.A. Times David Lazarus has the story of a California man whose teen daughter tore her anterior cruciate ligament while playing volleyball. After consulting with some doctors and getting an MRI, his daughter had surgery — approved by Aetna — to repair the ACL.

All seemed fine until the dad received a $6,000 bill for an MRI that had been performed before the surgery. The insurance company said he was responsible for the cost because the surgeon hadn’t gotten proper pre-approval for the scan.

And the hospital said he’d signed a waiver agreeing to pay any bills the insurer refused to pay.

The dad argued — and several surgeons agreed — that the MRI was part of the surgery and that no surgeon would have performed the surgeon without one.

His attempt to EECB the top brass at Aetna went without a reply. But when Lazarus got involved, Aetna suddenly labeled the whole thing a “misunderstanding.”

So why don’t they listen to the patient when they do get caught in the middle (unless they happen to get major print media involved)?

The rep says that the doctor — and not the patient — is actually responsible for the error, but that a coding error is responsible for the letter from Aetna saying the patient was on the hook for the $6,000.

In the end — and again, only because a high-profile L.A. Times columnist got involved — Aetna decided to pay for the MRI and scold the doctor for not seeking the proper pre-approval for the procedure.

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This seems like those situations where mail-in rebates are processed “incorrectly” resulting in the customer not getting their rebates. It’s funny how high (and seemingly acceptable) the rate of error is by companies when that error means they get more money.

I swear if we went to a unified and standardized medical billing system with forms, codes, and descriptions the same for all insurance carriers we would be in much better shape. Everyone in the medical industry is constantly complaining that all the billing practices for every insurance company are radically different and they often change in minor yet very critical ways.

Actually the there is a standardized code for this, IDC. However it is so huge and complex that it is extremely easy to choose a code for a something that seems fine, but will result in an insurer not covering it. The problem being that the same basic procedure gets a different code depending on the circumstances and each insurer covers different things based on the plan the patient has. Some patients plans require pre-approval or a referral or some other thing to be covered. For instance the same scan may be covered in an emergency room setting but not as an outpatient for diagnoses. The unbelievable variety of codes to choose from within the standard and widely varying patient coverages is the issue.

You want to make it even more confusing, try being self employed like I am and having different insurance for each family member and trying keep straight what is covered and what you can’t go to the doctor for for fear that you’ll get labeled with a pre-existing condition so you can’t even get insurance anymore.

If you find yourself getting things rejected for coverage, don’t give up, call your doctor’s billing staff and check on the codes they used and ask them to re-bill it with a different code. They know the system sucks and are often willing to help. Also, don’t just accept a rejection by the insurance company, they’ll often cover things if pushed. Finally, if you have a bill to pay, check with the hospital or doctor about payment plans and cash discounts or other ways they can work with you. I’ve found medical billers to be really great about this kind of thing if you ask nicely.

And if you think the complexity of the system is bad now, wait until ICD-10 rolls out in 2014. We tend to exaggerate in my company by talking about the different codes for left leg broken, right leg broken, right leg broken in auto accident, right leg broken in skiiing accident, right leg broken in skateboarding accident, right leg broken by Kathy Bates — but it’s only a slight exaggeration, sad to say.

We do have a system, and it’s extremely standardized. I write software that relying heavily on it. And dear god is this system BIG. BIG AND COMPLICATED AND MASSIVE AND BEYOND THE ABILITY OF ANY ONE HUMAN TO UNDERSTAND IT ALL.

That’s actually a myth perpetuated by companies who do medical billing, or train staff to do it. I was a medical office business manager for years, and there is very little magic or mystery in it. I won’t say a monkey could do it successfully, but it doesn’t require rigorous training or much brainpower to get it right.

NOT sue an insurance company for breach of the insurance contract
NOT sue an insurance company for Insurance Bad Faith
NOT sue an insurance company for any damages caused by the wrongful denial of benefits no matter how egregious, outrageous, or malicious is the conduct of the insurance company
NOT sue for punitive damages no matter how egregious, outrageous, or malicious is the conduct of the insurance company
NOT have the right in many instances to admit ANY evidence in a trial against the insurance company
NOT get a jury trial
NOT get any kind of trial in many instances
NOT sue in state court. In most instances the policyholder must sue in federal court, which is generally more conservative than state courts
NOT be entitled to insurance benefits sometimes, even if the policyholder proves that the insurance company was wrong when it denied the claim
NOT be entitled to insurance benefits, unless it is proven that the insurance company acted in an arbitrary and capricious manner
NOT be entitled to conduct any pre-trial discovery, such as taking depositions of insurance company witnesses in many cases.

Every year, something like this happens to some member of my family. We haven’t tried to get a newspaper involved, because the dollar amounts aren’t that much, and usually the doctor can re-submit the claim with whatever paperwork the insurance company wants, but sometimes, we’ve had to pay it.

“We definitely don’t want the patient getting caught in the middle.” Bullshit. That’s exactly what they want, or they wouldn’t have those rules in place, or be rewarding claims-takers for their level of claim rejections.

Having insurance companies gatekeeping medical reimbursement is like requiring bicyclists to wear water wings.

Sounds like something a chiropractor tried to pull on me, back before I knew chiropractic is a 95% garbage. I had insurance but they send me a bill almost a year after I had wised up and stopped going, so I told his peon she would have to write it off or send it to collections, because I was not about to pay. Collection agency tried coming after me and I told them 1) I knew what my rights are. 2) Contact me by postal mail only. 3) I was disputing that I owed anything, and 4) send me an itemized list of all the charges I supposedly owed. Once they realized I wasn’t going to be intimidated and would put up a fight, they wrote off the “charges”. I think the scam artist of a chiroquacker was having a problem bringing in enough new patients to sustain his “practice” so he started trying to milk former patients.

Chiropractic is a wonderful thing. I go to one myself, and the difference has been stunning in my flexibility, comfort, posture, and health, as I am not as tired during the day anymore.
My hubs threw his back out badly recently and he went to our “traditional” chiro for treatment. He could not walk on his own for an entire week. Within two weeks, he was walking fine. Within 3 weeks, he was back at work, and within a month, he was completely healed. Traditional medicine can only hand him stacks of prescriptions, and he would probably still be in pain for years.

I WILL admit there are GOOD chiros out there and BAD ones. You hit a bad one, I guess. If they advertise for car accident victims and/or offer or require X-rays, you can pretty much guarantee you got a bad one. Search elsewhere. Look for a traditional back-cracker. I bet you’d change your tune with some real results.

Chiropractic solved it for your husband but sometimes it can actually cause more harm than good. My dad saw a chiropractor after some minor back pain and ended up with a ruptured disc that involved surgery. He originally had minor pain and after one visit couldnt walk across the house. Yeah, there are good and bad ones but the physical therapists and surgeon both said they see at least 2 cases a day related to the bad ones. If it makes you feel good, then do it but know that in the end you may cause yourself some harm.

If there is a physical injury to the spine or disks, a chiro cannot help. Even ours tells us this. My hubs had X-rays in the ER so we knew that his spine was physically okay, it was all muscle damage. If there is a specific traumatic injury like he had, X-rays should be taken as a precaution, because yes, a chiro can do more harm than good in those situations. But on the other hand, having the routine treatments done when one is NOT in any pain helps in posture, strengthens muscles in the back, and can help prevent those types of spinal injuries in the normal course of a day.

Someone we know just threw his back out while getting out of his car. Again, muscle injury. But, he could have avoided all those days of pain if he had the treatments and his back muscles had been stronger overall. The same exact injury (pain on getting out of a car) happened to a relative of his, and that person has been on disability for years and still has big back issues. This could have been prevented!

If you can find a good, common-sense chiro and you become an educated patient, a whole lot of good for you can come out of it. No, it’s not for everyone, but rage against the whole practice only after dealing with one chiro without exploring other options, to me, is the wrong way to look at it.

A lot of the ill will against Chiropractors comes from the ones in England – they make outrageous claims (Cures Cancer! And AIDS!) and charge the government outrageous amounts of money while they’re doing it. They don’t do it in the US (as much) but you should keep in mind that your back is very vulnerable, and messing it up can be very serious and permanent. Talk to your doctor before going to a chiropractor, do some research, make sure that the problem you have can be solved by one.

Oh, and realize you’re taking the risk of being crippled for life if the chiro fucks up.

You don’t know what you are talking about. There is very, very poor scientific evidence that shows that chiropractic “medicine” is effective and worth the risks involved. It has nothing to do with “good” or “bad” chiropractors and everything to do with science.

And “just give him pills”? Are you kidding? You’ve never heard of physical therapy?

The chiro specified some stretching exercises he could do daily or more often at home to speed recovery. This is physical therapy. Can’t remember what he called his injury specifically, something socket something. Basically said one of his vertebrae was kind of “jammed” or “stuck” in a position that caused the muscles to react and tense up, causing the pain and pointed out the specific spot. After the stretching and walking exercises at home, and muscle stretching, and adjustments, he went in one day about a week into it, got the adjustment and the doc said “there it goes” meaning that the muscles finally loosened up enough allowing the joint to finally go back into proper place, he could feel it, and it was all much more rapid healing from then on. He is 100%plus healed today and says he actually feels better than he did years ago. No more stiffness or pain in his neck or hips which he used to get working on the computer for long periods of time at work.

Years ago, I used to get adjustments from my doctor – a family physician with an actual medical degree (gasp!) and she said it was a great thing to do to keep the body healthy. My mom recently broke her arm and asked questions about it while getting therapy and the physical therapist said it was a great thing and has been giving her adjustments included with her arm therapy because she said it was a great healing tool. So, there’s two reputable sources.

Perhaps writing off your past bad experience and looking at it with a more open perspective (and a better chiro) might change your view. I’ve had horrible experiences with various medical doctors over the years, especially specialists for some reason, but that doesn’t mean I curse them all with one brushstroke.

When we got our new (read: much more expensive) health care plan at work this year it came with a ‘complementary’ middle man service who’s main objection is to act as a negotiater if you and your insurance or your insurance and your doctor have a financial disagreement. The sales lady explaining this service kept giving examples of people she knew who had to fight their doctors/insurance companies over charges that should have been covered but instead were sent to them as a bill, exactly like this post describes.

After 20 minutes I raised my hand and asked her why the hell we required an additional service to make insurance companies and medical billing departments do their damn job. She literally could not answer the question. Lucky for me my company is paying for this service and not directly charging the employees, but for most people they’d pay an additional monthly fee on top of already outrageous insurance premiums just to negotiate charges which should be paid by the insurance anyway. WTF is going on here?? I don’t think the free market is able to keep these insurance companies from FUBARing claims.

The AMA should issue a directive to all doctors to just quit doing “pre-approval” for ALL medically necessary procedures. Then if the insurer thinks it wasn’t necessary, they can just refuse to pay on THAT basis alone (and usually lose and be forced to pay). Doctors need to spend their time doing medicine, not paper or e-paper work.

There probably isn’t a great reason. I could see health insurers though asking for preapproval if only to prevent duplicate testing from being done.

If you go to to your PCP and he or she orders a bunch of bloodwork and then refers you to a specialist, should the specialist go back and redo the exact same tests again? This actually happens sometimes, and really only the health insurer cares enough to prevent that kind of thing.

Err, I think someone’s confusing success and failure rates. A 20% failure rate in baseball would be batting .800. A 20% success rate would be batting .200, which is known as the “Mendoza line” which is sub-par performance. Now a 30% success rate is a whole ‘nother story, not to mention the elusive 40% success rate.

How about a 33% failure rate on state tax returns? In 6 years of living in the state I am now, TWICE they have screwed up my tax form entry into their database. (I mail it in so I don’t have to pay extra for the efile. It’s a small amount, and it gives me a surprise check around June.) Both times, I had to write a letter to the tax office telling them to FIX IT! Which they did, but still 1/3 of the time a state tax office cannot input returns correctly? WTF?

Meant to add: If one out of five are processed incorrectly, and the assumption is they are in favour of the insurance agency, than something is seriously wrong and people are being taken advantage of. Even if they are honest mistakes or simple inefficiency, healthcare and the large amount of money involved should be held at a higher standard. That many mistakes should be inexcusable.

I am an orthpaedic physician. It is typical nowadays for the MD’s office to get an authorization for MRI’s. It is not at all part of the surgical charge. Typically the hospitals, at least in my area, won’t perform MRI’s without the insurer’s authorization in hand. Surprised this was performed in this person’s case. A shame they had to go through all this hassle

It used to be I could send an order to the hospital and get an MRI done easily without the need to jump through the hoops of contacting an insurer for pre authorization for an MRI/CAT scan, etc. Big wase of my office’s time.

My theory (which is probably wrong) is that because medical school costs so freaking much, the doctors need to have high paying jobs when they finish school just to pay the student loans and then (a decade or so down the road) after the loans are paid off, they probably aren’t looking to make less money than when they started. To afford those salaries, the money has to come from somewhere. Also, you need to pay the medical supply companies. The new and great MRI machine costs a ton of money and so you need to charge enough for that to cover that cost over a certain number of MRIs plus overhead and nursing costs. It’s huge.

It costs $6,000 because most people never see or even care what the total cost is. Very few consumers shop around for the best prices on diagnostics or lab work because there’s no incentive for them to do so.

I needed an MRI a few years ago (back when I had a $5,000 deductible) and found that prices varied considerably, from $700 at Radiology, Inc. to over $2,000 at the county hospital (I can’t remember the exact prices but it was in that ballpark). If I had better insurance, I wouldn’t have cared — I would have just gone to whichever place was closer.

and I bet if you called a facility with an MRI and asked them what it’d cost for a procedure they couldn’t tell you either. Healthcare in this country is so many kinds of fucked the providers can’t tell you how much something is going to cost up front, and the ones that can tell you are lying.

I had a similar situation. I underwent a 25-day treatment for a medical condition. I called my insurance company to verify it was covered. The treatment could not happen without the doctor checking me everyday and instructing the nurses on what to do, so the physician visits should have been considered part of the treatment. Instead, I got whacked with $900 in doctor visit co-pays that I didn’t expect. I filed an appeal with Blue Cross and lost.

Several of my treatments/tests for myeloma have caused billing errors, sending us multi-thousand dollar bills. In each case a call to insurer lead to a call the Dr to have them send X or Y document and it’s all handled.

I went to the ER last June for a kidney stone. My crap insurance has a $2000 deductible. The bill was $1600. I have bills from 4 (4!) different offices for the various services performed. Ill be making monthly payments on two of them for another 2 years. Do we need some standardization such as Derigiberble suggests? I think so. 1 visit, 1 bill, let the hospital sort it out.

A $2,000 deductible isn’t too bad. Mine is $10,000 and before that it was $5,000. Low deductible insurance is nice but I can’t justify spending $1,200 or $1,500/month for a PPO.

But I do agree with how hard it is to handle medical bills when there are so many hands in the pot. It also creates the added stress of any involved provider making a billing mistake or being out-of-network.

It’s stories like these that make me wonder where we will be if print media ever dies. Maybe the local TV affiliate will pick it up but will they last? I think I am more likely to read a newspaper before I watch my local TV news.

These MRI costs are ridiculous no matter who pays. My wife had an MRI on one of her feet at a major hospital in Spokane, WA. She had to pay the hospital $500.00 up front as a supposed co-pay. After the MRI the hospital billed us $4500.00 for the procedure. When the insurance kicked in the total charged was Blue Cross was $500.00. Exactly the amount of the co-pay. Coincidence? If a single foot costs $5000.00 how much would a whole body be â€“ $500,000.00?
Remember, the United States has the best health care system in the world â€“ if you have insurance or are wealthy.

This is an addenda to my earlier post concerning the cost of an MRI on my wife’s foot. A few months after that I had an MRI done in an orthopedic surgeon’s office for what turned out to be a torn rotator cuff and ligament. I am 70 years old. The doctors charge for the MRI was $300.00 because medicare limits the amount that can be charged. I can’t wait until my wife turns 65 in July.

I can relate. I’m waiting for Anthem Blue Cross to either approve or deny an MRI that will help determine what kind of heart surgery I’ll need. If they approve it, I get the MRI. If they deny it, i got in for exploratory surgery.

But since they haven’t done either yet, I’m stuck waiting.

(I don’t know the specifics, but it isn’t a standard MRI. I’ve had a few of those in the last year. This is some kind of new one, and the radiologist won’t even perform it without authorization from my provider.)

Agreed, it’s so awful to be up here in Canada, where we have to wait for crucial surgeries. Like my grandmother who went in to the hospital last month with shortness of breath and they discovered fluid around her lungs due to a malfunctioning valve that had been replaced a few years earlier. She had to wait so long for surgery to replace the valve [and another one a well] – I think it was like a week. Seven whole days!

We should totally trash this healthcare thing we have and go with the American style, I agree. I think my grandmother has entirely too much money left. She should be broke and happy because she’s alive, dammit!

The 20% failure rate is 100% intentional. Health insurance companies intentionally “screw up” bills. They hope you will not notice the “error” or that you’ll decide it’s too much trouble to fight it and they get more of your money. The failure and mistake rate is simply too high for any other explanation to fit.

My recent MRI billing experience: I went through a brawl a few months back where my insurance company COULD NOT EVEN UNDERSTAND THEIR OWN POLICY. I needed an MRI, they claimed I need pre-auth, then they said I didn’t, then they said I did, blah blah blah. End result is that they gave me false information – multiple times – causing me to have my MRI in early January instead of the late December it would have been had I been given correct information. Early January, of course, means a reset of out-of-pocket expenses and deductibles. When I complained to my company, they got it so that the MRI counted against 2011 instead of 2012 for deductible purposes. The insurance company then billed me incorrectly 3 times before finally getting it straightened out.

Again, all because the insurance company themselves COULD NOT UNDERSTAND THEIR OWN POLICY.

My experiences with Aetna have actually been largely positive. I mean, as positive as dealings with a health insurer could be.

I’ve called a few times to complain about billing issues and I’ve actually been put on hold while a CSR calls my doctor to get a bill resolved, almost always to my satisfaction. I’ve had similar luck with BCBS Texas. Now UnitedHealthcare is a different story…

Cannot say how many times in the last 7 years I’ve had to fight with insurance companies and doctor’s offices over paperwork. It got to the point where I asked for a hard copy of each and every referral.

There are several problems which all stem from the sense of entitlement and/or pricing based the premise someone else is paying for it.

With the large dollar amounts to be gained from the medical insurance industry they have put processes in place to prevent the exploitation of their customers policies and their piggy banks. In the mean time these providers feel entitled to a billing price based on maximum third party reimbursement.

Yes the patient is caught in the middle of administrative nightmares that wouldn’t even exist if no one providing or using the health care industry based costs on third party reimbursements.

What bugs me here is the provider feels entitled to their desired fee even though by accepting an insurance company reimbursement which theoretically is supposed to set ” a fair ” price for their services. So a provider is basically throwing insurance company reimbursement criteria back in their face by having their patients sign a waiver which shouldn’t even be given to a patient.

You don’t have an advocate in an insurance company and you have to do your own research on available service & price but if you have the time and means why dump money into an insurance company. Cash can put your personal finances at risk but so can paying a thousand a month to insure a family. It takes you time just to research your insurance company guidlines and available services & doctors so why not research the competition at the sametime. The medical providers get paid when you pay cash and not alot of clerks and administrators in the insurance industry.

Until the medical insurance industry is fully renovated and/or reformed you will have both providers and patients wasting time on third party battles.

Sad but true medical insurance companies do this on purpose— a colleague of mine reported that companies purposely goof up on a number of claims in order to maximize profits (literally throwing a bunch of received envelopes into a bin) and hope consumers don’t follow up on them.

It’s profitable to make mistakes in the insurance industry and without a watchdog oversight to penalize insurance companies, you can bet this practice will continue.